0720T
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled Medical Records Documentation Used for Reviews. For FES for lower limb paralysis due to SCI, documentation should demonstrate each of the listed required criteria (exact wording):
- Demonstration of intact lower motor units (L1 and below) (both muscle and peripheral nerves)
- Muscle and joint stability for weight bearing at upper and lower extremities that can demonstrate balance and control to maintain an upright support posture independently
- Demonstration of brisk muscle contraction
Key Coverage Criteria
- Transcutaneous electrical nerve stimulator (TENS) is proven and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to the InterQual® CP: Durable Medical Equipment, Transcutaneous Electrical Nerve Stimulation (TENS). [...]
- Peripheral nerve stimulation (PNS) to decrease chronic or acute pain by stimulating peripheral nerves with leads placed adjacent or parallel to the affected nerve
- PNS for use as a trial to assess pain-relief effectiveness prior to permanent implantation
- Peripheral nerve field stimulation (PNFS) for pain localized to a region serviced by multiple smaller peripheral nerves or nerve endings when a single nerve is not clearly responsible
- Electrical stimulation of the dorsal spinal cord for relief of chronic neuropathic pain disorders.
- Persistent, intractable pain of nerve origin that is refractory to standard pharmacological and surgical therapies.
10 Active Policies
AMBETTER-CP.MP.117 — Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation
UHC-POL-electrical-stimulation-treatment-pain-muscle-rehabilitation — Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
UMR-POL-UMR-electrical-stimulation-treatment-pain-muscle-rehabilitation — Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
SUREST-POL-SUREST-electrical-stimulation-treatment-pain-muscle-rehabilitation — Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
Related Codes
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